DONATION FORM

COMPANY NAME: ______________________________________________________

ADDRESS: _____________________________________________________________

CITY: ________________________  STATE: _________________  ZIP: ___________

TELEPHONE: __________________________ FAX: ___________________________

AMOUNT OF DONATION (circle donation amount):

$100    $200            $300            $400            $500            $1000

OTHER: $_____________________

RECEIPTIENT (please circle charity of your choice):

AMERICAN RED CROSS               UNITED WAY            NYC RESCUE MISSION SALVATION ARMY             CATHOLIC CHARITIES            H.E.L.P.         N.E.R.T.     FEDERATION OF ORGANIZATIONS             PHOENIX HOUSE    W.I.N.    OPTIONS FOR COMMUNITY LIVING            PRODJECT REDIRECT            SAFE HORIZON VICTIM SVCS  HOPE CHEST            VOLUNTEERS OF AMERICA

FEDERATION OF PROTESTANT WELFARE AGENCIES

OTHER:__________________________________________________________

______ ALLOW START-RITE, INC. CHOOSE THE CHARITY

PAYMENT METHOD:

_____ CORPORATE CHECK

_____ CREDIT CARD

MASTERCARD   VISA      AMERICAN EXPRESS            DISCOVER

ACCT.#_________________________________________________________________

EXPERATION DATE:___________

AUTHORIZATION :___________________________________________